I thank the Anna Education Committee for inviting me to present this technique, and specifically John Kelly for inviting me to do this talk as well as giving it a title that makes me sound certainly quite confident. My disclosures are on the Academy website. So today I want to present our technique of arthroscopic supracapsular reconstruction utilizing push-in glenoid anchor fixation instead of the more commonly discussed suture shuttling techniques. In our practice, this is the technique we have utilized for all of our SCR procedures. I'll also discuss lessons that we've learned along the way on our journey of performing this procedure. So Dr. Mahada introduced supracapsular reconstruction to the world in 2007. His original technique utilized fasciolata autograft to reconstruct the superior capsule and restore glenohumeral mechanics lost in patients with massive rotator cuff tears. He reported a successful restoration of function and pain relief in his patients with truly remarkable results in specifically ASCS scores reaching 93. Enthusiasm for this procedure greatly grew throughout the world, especially after Dr. Hirahara and Adams introduced their technique of arthroscopic supracapsular reconstruction with acellular dermal allograft. There are several clinical studies in the literature now documenting early results in supracapsular reconstruction with promising results. Recent systematic reviews that were published actually in this month's arthroscopy have demonstrated consistent, acceptable short-term results in treating this problematic patient population with consistent improvements in pain, range of motion, and shoulder function. As with any procedure, outcome optimization is facilitated by understanding the indications during patient selection for supracapsular reconstruction. Indications for SCR in active patients are those patients with massive irreparable rotator cuff tears involving the supra and infraspinatus tendons, minimal glenohumeral arthritis, well-functioning deltoid and trapezial musculature, and intact or repairable subscapularis musculature. Our technique evolved from our early experience when performing SCR with the typically described double-pulley graft advancement technique. In my first few cases, we had failure securing the graft to the glenoid, which the suture broke during knot tying or the suture pulled out, or the suture anchor pulled out of the superior glenoid neck during knot tying. The bailout procedure that we employed was utilized on push-in suture anchor and suture tape sutures to serve as a salvage procedure in performing this technique with fixation on the glenoid side with the push-in suture anchor and suture tapes. We perform all these procedures in the lateral decubitus position with the arm at 45 degrees of abduction and neutral rotation. The portal configuration that we utilize in this procedure is exactly the same as we use for arthroscopic rotator cuff repair. No additional portals. The anterior and posterior portals are working portals. The mid-lateral portal is a viewing portal, and the juxtachromial portal is utilized for graft introduction and fixation of both the glenoid and humeral sides of the graft. The video on this slide demonstrates an arthroscopic view of a right shoulder from the mid-lateral portal. The humeral head is on the top of the screen and the glenoid on the bottom. Spinal needle guidance is utilized to assure juxtachromial portal placement that facilitates access to the glenoid and humeral head. A flexible cannula is placed in the juxtachromial portal that is sufficient for graft passage. After the superior labrum is removed and the superior glenoid rim and humeral footprint is abraded, three anchor holes for the pushing anchors are placed in the superior glenoid. Two medial roll screw-in anchors with suture tapes are placed in the humeral footprint. Graft dimensions are obtained with an intra-articular measuring device and are utilized to fashion appropriately sized acellular dermal allograft. The graft is prepared with proper dimensions. Three suture tapes are placed on the medial aspect of the graft to be utilized for graft advancement and glenoid fixation. Lateral holes are punched for medial roll humeral fixation. This picture demonstrates the graft prior to placement. The middle tape is marked with a surgical marker to assist with orientation viewed arthroscopically. We typically inject the graft with biologics such as PRP prior to graft placement. This video demonstrates graft insertion utilizing the anchor shaft to push the graft through the juxtachromial portal. This video is a left shoulder demonstrating fixation starting from the posterior superior anchor on the glenoid while working anteriorly. The graft is fixed medial to the glenoid with three push-in anchors and three suture tapes. We prefer this technique as it's knotless and the push-in anchor shaft facilitates graft advancement into the joint. After the glenoid side of the graft is secured, lateral fixation is provided with a double row transosseous equivalent repair technique. Side-to-side closure of the graft to remaining anterior and posterior structures is performed to restore the force couples and provide appropriate graft tension. You'll see the lateral fixation and the side-to-side repairs in that photo. This video demonstrates a restoration of superior stability to a superiorly translatory force after proper graft tensioning is prepared. This is what you're shooting for in these cases. This postoperative radiograph demonstrates a typical increased acromiohumeral distance achieved from recentering the humeral head after an appropriately tensioned superior capsule reconstruction. This video demonstrates one of our failures. All of our failures that we've documented to this point has been on the humeral side of healing. The graft appears to be well healed on the glenoid with neurovascularization grossly visualized in the video. We've reported our results of this technique in the Arthroscopy Journal with similar promising short-term results from other series. As stated earlier, all short-term results of SCR are promising and need to be followed to validate long-term value of this procedure. As this procedure burns no bridges, future reconstructions are possible in those patients that don't do well. An additional application of this technique is in the form of augmentation during massive rotator cuff tears. In our experience with superior capsule reconstruction of massive retractive rotator cuff tears, we've noted that approximation of the rotator cuff to the native footprint was facilitated by performing concomitant superior capsule reconstruction. Performing SCR to augment these massive tears theoretically protects the repair by restoring superior capsular stability, decreasing tension, providing soft tissue augmentation by providing biologic scaffold and protects the repair by restoring proper glenohumeral mechanics. As with any new technique, lessons we have learned all go back to remembering that good patient selection leads to optimization of results. Accuracy repairing the rotator cuff is the number one priority when performing these procedures. Proper tensioning of the graft is essential. Be cautious with those patients that have arthritic changes. Don't push it as the arthritis will advance. As many of these patients will be referred to you after having multiple failed procedures, make sure that the deltoid is fully functional and there aren't pre-existing nerve issues. Specifically, also pay close attention to subscap status. Whether it's torn, whether it's repairable, and pay close attention to associated atrophy. This following video is one of my favorite videos of a patient that underwent this procedure of the many that I've taken through the years where he wants to show off. I wasn't expecting him to do that. I did not coach him on that either. So in summary, we employ this glenoid fixation technique when performing arthroscopic supracapillary construction due to its ease and due to the fact that we utilize the same portal configuration as rotator cuff repair. The anchor shaft is utilized as a graft insertion device. There's less need for suture shuttling. The subchondral bone of the glenoid is uniformly strong for fixation. Suture tape provides stout, soft tissue suture interface with strength, and it's a knotless technique that's very efficient and reproducible, and our operative times are typically less than one hour in this procedure. Thank you.

arthroscopic supracapsular reconstruction

massive rotator cuff tears

pain

range of motion

shoulder function